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RRP 12-446 – HSR&D Study

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RRP 12-446
Integrating Tobacco, Drinking, and Depression into the STOP Stroke Tool
Sonia A. Duffy PhD MS RN
VA Ann Arbor Healthcare System, Ann Arbor, MI
Ann Arbor, MI
Funding Period: February 2014 - March 2015

BACKGROUND/RATIONALE:
The Self-management TO Prevent (STOP) Stroke Tool is a reminder dialog application in the computerized patient record system (CPRS) that prompts clinicians on clinical practice guidelines (CPGs) for secondary stroke prevention, while simultaneously facilitating patient/provider shared decision-making and collaborative goal-setting around stroke risk factor management and patient self-management actions. Risk factor management modules for antiplatelet-anticoagulation therapy, hypertension, diabetes, hyperlipidemia management, improving physical activity and collaborative goal setting were developed and tested in previous research. Veterans who have experienced a stroke are at risk for smoking, problem drinking, and depression and these behaviors/disorders are likely to decrease self-management and increase the risk of recurrent stroke.

OBJECTIVE(S):
The purpose of this pilot study was to integrate and test state-of-the art, evidence based smoking, problem drinking, and depression modules for stroke patients as part of the STOP Stroke Tool.

METHODS:
This used a mixed methods design to integrate modules based on VA/DoD CPGs for smoking, problem drinking, and depression into the STOP Stroke Tool. Phase 1 consisted of a formative evaluation on the integration of the new modules into the STOP Stroke Tool by observing and obtaining feedback from 5 providers and 9 veterans on barriers and facilitators to using the new modules while interacting with the STOP Stroke Tool during a simulated clinic visits. After modifying the modules based on provider/patient feedback, phase 2 consisted of a pilot implementation of the new modules by assessing 60-day reductions in smoking, problem drinking, and depression.

FINDINGS/RESULTS:
Phase 1
Human-factors methodology was applied for usability testing to pretest the smoking, problem drinking, and depression modules with providers (n=4) and Veterans (n=6). Using transcripts from the audio-taped sessions, content analysis was applied to code word and word phrases into pre-defined categories that were indicative of barriers or facilitators to accessibility, usability and usefulness of the modules. Providers indicated "access to the tool in was easy", but knowing "when to use the tool was unclear". The use of a reminder to activate the tool for patients was viewed as "not helpful" as providers indicated they are already "overburdened with mandatory reminders". There was concern about "duplication of effort" with other required templates being used by providers. Barriers associated with the general use of a computer-based tool included: "decreases eye contact", "interferes with interaction" and "gives an impression of disengagement". All providers found the educational materials embedded in the tool to be "helpful" and "useful". The automatic link to smoking cessation and antidepressant medication in the tool was also viewed as "helpful" and "useful".

All patient participants liked the Tobacco Tactics manual and most "preferred the paper" form of the manual" and all indicated they "would not use the Website version". Patients had positive responses about using the tool with their provider including "helped me understand what I need to do", "took time to go through it with me", and "gave me a guide to follow".

Phase 2
The smoking, problem drinking and depression modules were modified based on provider/patient feedback and then were incorporated into the existing STOP Stroke Tool in CPRS. A pre-post design with patients that had experienced a stroke was used to pilot test the implementation of the STOP Stroke Tool in primary care and specialty care clinics during clinic encounters with stroke patients enrolled in the study. Of the 42 participants at baseline, 26 responded to the 60-day follow up. Study participants were, on average, 64 years old, male (97.6%), non-Hispanic (85.7%), mostly White (69%), retired or disabled (78%), served during the Vietnam era (69%) in the Army (48%) and without combat experience (68%). There was no statistical difference between the demographic and smoking, alcohol and depression characteristics at baseline of 60 day follow-up responders and non-responders.

Smoking
At baseline, 81% reported having smoking in the past 7 days, while 77% reported smoking at follow up, with 1 (5.3%) reported to have quit. Nicotine addiction, assessed by the Heavy Smoking Index (HSI) was 2.3 (SD=1.8) at baseline and 1.9 (SD=1.8) at follow up. The mean number of days smoked cigarette at baseline was at 5.9 (SD=2.3) which went down to 5.1 (SD=2.5) at follow up. On average, the number of cigarettes smoked at baseline was at 14.8 (SD=11.2), which went down to 11.8 (SD=10.1) at follow up. The proportion of study participants who reported that quitting smoking is very/extremely important went up from 78% at baseline to 84% at follow up. The proportion of study participants who reported that they are very/extremely confident to stay quit smoking went up from 22% at baseline to 32% at follow up. However, the proportion of study participants who reported that is very/extremely difficult to quit smoking also went up from 47% at baseline to 68% at follow up.

Alcohol Use
The Alcohol Use Disorder Identification Test (AUDIT-C) was used to evaluate alcohol use/misuse. The mean AUDIT-C score at baseline and follow up was 2.2 both (SD=2.8 and SD=3.2, respectively). At baseline, the proportion of problem drinkers, defined as having AUDIT-C of 4 or more for males and 3 or more for females, was 28.6%, which was significantly reduced to 0% at follow up (p=0.0012) with all of the 26 study participants, all males, having AUDIT-C less than 4.

Depression
The Patient Health Questionnaire (PHQ-9) was used to evaluate depression at baseline and follow up. The mean PHQ-9 score at baseline was 5.7 (SD=4.5), which went up to 7.0 (SD=5.6) at 60-day follow up. The proportion of study participants with major depression, defined as having PHQ-9 of 10 or more, at baseline was 21.4% and at follow up was 30.8%.

IMPACT:
It is feasible to integrate evidence-based interventions for smoking, problem drinking, and depression within the STOP Stroke Tool to create a comprehensive decision support application that facilitates patient-provider communication and documentation of stroke risk factor management and patient self-management actions. While there were modest improvements in smoking and problem drinking in this small sample, more research is needed to determine the effectiveness of the intervention on patient outcomes.

PUBLICATIONS:
None at this time.


DRA: Substance Abuse and Addiction
DRE: Prevention
Keywords: QUERI Implementation
MeSH Terms: none